What All Parents Can Learn from a Feeding Therapist

This post is the second in a series from an interview with Dr. Ramasamy Manikam, PhD, a clinical psychologist and top expert on feeding disorders with over 20 years of practice. Dr. Manikam is the Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children.

Compared to most of us parents, Dr. Manikam has experienced far more challenging situations at mealtime than what we face at our own tables. He is also a parent and grandparent. In this post, he shares his experience and perspective for all parents, including how to deal with “picky” eating issues such as color, texture, food jags and other common food concerns.

First, the most important message for all of us parents is that minor food issues — such as typical “picky” eating — are perfectly normal. The other important advice is we shouldn’t worry so much about food that we cause a larger problem.

“I would consider picky eating in healthy children a “normal” phase of development, usually during transition from bottle to solids and especially from puree to textured foods,” says Dr. Manikam. “Children tend to ‘try’ new foods and spit them out if the food does not meet with their interest (smell, taste, texture, color, etc.). Continued presentation without pressure, in small amounts, and in a variety of preparations can eliminate the problem.”

Another good thing to remember, Dr. Manikam advises, is not to get hung up on your child “having” to like any one food.

“No one food ‘has to be eaten’ unless for medical reasons,” he explains.  “If a child is healthy and is taking a variety of other foods there is no reason to “force” the child to eat a certain food (sometimes it is a power struggle that the parent wants to win for no good reason).”

Food should not be a fight, Dr. Manikam, advises, which is perhaps the best message parents could hope to hear. For those of us who deal with the challenges of our kids’ food issues daily, however, Dr. Manikam offers some good strategies for how to solve the issues and avoid that conflict.

Food Jags and the Mac-and-Cheese Strike

So, what about particular issues, such as a food jags where a child refuses to eat anything besides the Evil Trinity of fat-sugar-salt, i.e. mac-and-cheese, fast food or chicken nuggets?

“Choose foods with similar characteristics such as color, texture, taste, etc. to reduce the child’s resistance,” Dr. Manikam advises. “Introduce new foods in small amounts, mix the two foods together where possible, make the new foods interesting like making them into interesting shapes, arrangements etc.; model eating the food with the child; find out what about the new foods the child dislikes: e.g., color, taste, smell, texture, etc and manipulate these food characteristics.”

Color Issues and the All-White Diet

Quite often, kids refuse to eat any food of a certain color, green for example, after one negative exposure to a green food. It doesn’t matter if the new food is juicy grapes or sweet kiwi fruit, all things green equal broccoli. Other children may refuse any food that is not white, beige or brown, otherwise known as the “white diet.”

Many of the same approaches for food jags, above, are also useful for a color aversion, says Dr. Manikam.

“It takes many tries to get a child to feel comfortable with new foods. Frequent introduction of new foods because the child refuses a food is not a good idea. Continue to introduce the same food for 16 to 20 times, experimenting with a variety of food preparations.  Strong resistance might have an underlying problem and not merely a ‘behavior’ problem and should be medically evaluated.”

Texture Issues

Texture issues, whether it is a preference for crunch or for soft textures, can be confusing since they show up across all different flavors and colors of foods. For kids with texture issues, Dr. Manikam advises parents to try and evaluate the source of the issue in case it is not just picky eating.
“Check to rule out oral-dental problems.  Rule out sensory issues.  Texture fading (gradually increasing the texture of the food presented moving from puree to thickened puree) is a strategy that works well most of the time in the absence of oral-dental and sensory problems,” he says.

Restless Eaters 

Some of us have kids who can't seem to stay still long enough to eat.  These kids are often slumping in their chairs, getting up and down, or won't want to eat a full meal but then say they are hungry an hour later.

For these eaters, Dr. Manikam recommends a consistent schedule and being aware in case there are legitimate causes of a small appetite.

“Frequent meal-time changes can be difficult for the child,” he says. “Routine in other areas such as naps also helps mealtimes. Ensure that the child is ‘hungry’ before meals. Do not give snacks before meals. Feed developmentally appropriate portion sizes. Check to see if there is a medical reason for poor appetite. Children with poor appetite might need mini-meals (six to eight sessions a day) with gradual increase in portion size.  Children when ill or when recovering from illness cannot consume a full meal and could use mini meals until fully recovered.”

The Separate Meal Request

Feeding a family with all different tastes can be a struggle. It’s tempting to give into the request for separate foods — even just to get through one difficult evening. Once this becomes a habit, some children may insist on always being fixed a separate meal of foods they request. What started out as an understandable quick fix solution for a busy and stressed parent now adds to daily stress with the extra planning and preparation of this separate meal. How do you get the whole family eating the same meal again?

“If the child is healthy and well developed a ‘premack’ strategy can be used (i.e., to have the child consume a bite or two of the family food before presenting the preferred food and gradually increase the amount of the family food); or have the child leave the table and tell the child he/she can eat at the next meal (do not deprive the child of other food routines between mealtimes including liquids and snacks). If the child is not healthy or cannot afford to lose weight then food fading (gradual introduction of small amounts), food masking (mixing and hiding with other foods), and premack strategies can be used, ensuring that the child gets the required calories and nutrients,” says Dr. Manikam.

How Do We Tell if a Food is Disliked Because of Color, Texture, or Flavor?

Younger children cannot always verbalize their exact issue with a particular dish. It doesn’t help that one recipe for carrots can taste completely different than another recipe. How can parents of younger children “crack the code” on why their children won’t eat a particular food?

“One way to identify what the source of the particular food is to use the ‘elimination’ technique, similar to identifying a food that a child is allergic to,” says Dr. Manikam. “Change one characteristic of the food at a time for a few meals to see if it makes a difference.  Also, identify what the common elements are amongst the food the child is consuming and then use these elements to the refused foods.”

Stress Less. Enjoy More.

Overall, Dr. Manikam offers advises parents to remember, “Every eating ‘quirk’ is not a feeding disorder. If the child is healthy with normal growth trajectories the ‘feeding issues’ are overcome through ‘common-sense’ actions and time."

He also advises us to simply enjoy our food as we introduce small bites of new foods to our children. Reintroducing a rejected food item is a good tactic. That small bite might get eaten after a few tries — just don’t force those bites, he says, or force your child to clean his or her plate.

If you find yourself still tempted to worry, focus on being sure your child’s menu is varied and provides adequate nutrition for his/her age and developmental needs.

Many thanks to Dr. Manikam, Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children, for his insights shared here. Read the first post in the series on feeding disorders and when a parent should worry.